by Stan L. Block, M.D.
Associate Clinical Professor of Pediatrics
University of Louisville and University of Kentucky

What is acute otitis media?

Acute otitis media is an infection of the middle ear, generally caused by bacteria.
In acute otitis media (i.e., an ear infection or an infection of the middle ear),
pus and infected fluid accumulate in the middle ear space.

The tympanic membrane (eardrum) appears inflamed, reddened, and often protrudes
outward. Usually, an ear infection begins after the eustachian tube (a small tube
connecting the back of the nose to the middle ear space) has become swollen, congested,
and closed, most commonly resulting from an ongoing viral respiratory infection.

Acute otitis media should not be confused with: 1) external otitis ("swimmer's ear")-a
painful bacterial infection of the superficial skin of the ear canal, or 2) otitis
media with effusion (secretory otitis or "fluid ears")-an accumulation of non-inflamed
fluid behind the eardrum. Otitis media with effusion is not considered infected,
and most doctors do not treat it with antibiotics. This uninfected fluid in the
middle ear is a remnant in 50% to 60% of resolved ear infections. It is frequently
a mild complication of colds, respiratory illnesses, or nasal allergies.

What causes acute otitis media?

Haemophilus influenzae (Haemophilus-but not the Haemophilus strain in the HIB or meningitis vaccine) in 20% to 30% of cases.

Moraxella catarrhalis (Moraxella; sometimes called Branhamella catarrhalis) in approximately 10% of cases.

Group A Streptococcus (like the strep bacteria of strep throat) in 5% of the cases.

The pneumococcus bacteria is now the most difficult to treat. Some strains have
become very resistant to antibiotics by using their unique ability to transform
their genes and cell wall into a bacterial form, which is resistant to most of the
antibiotics that commonly are used to treat ear infections. These resistant strains
frequently are cultured from children who do not respond to several courses of antibiotics.
When a child has an ear infection that does not respond to antibiotics, resistant
pneumococcus bacteria may cause it.

Pneumococcus has 90 different types, which are all genetically related; however,
7 types account for the majority of ear infections in childhood and nearly all of
the antibiotic resistant strains. In addition, pneumococcus is the leading cause
of meningitis, bloodstream infections, and serious pneumonia in children, sometimes
as a result of a preceding ear infection.

Up to half of Haemophilus and nearly all Moraxella bacteria produce an enzyme (beta-lactamase),
which makes these bacteria resistant to some of the commonly used antibiotics. This
enzyme may destroy many antibiotics when they come in contact with the bacteria.
Nonetheless, several available antibiotics are still quite effective against these
strains.

Viruses play a critical role in the development of acute otitis media by enabling
the bacteria to travel into the middle ear (see below). By themselves, though, viruses
account for only 6% to 10% of ear infections.

How does it cause disease?

As long as air entering from the back of the nose is able to reach the middle ear
space via the eustachian tube, the middle ear rarely becomes infected. The eustachian
tube in younger children is flimsy and easily collapses. As the child grows, the
cartilage tissue surrounding the eustachian tube becomes stiffer, longer, and more
angulated inside the skull.

Pneumococcus, Haemophilus, and Moraxella commonly reside in the back of the nose,
and do not infect the child. Once a child becomes infected with a respiratory virus,
it not only causes congestion of the nose and the lungs, but also of the eustachian
tube. When this tube becomes clogged, the cells in the middle ear space produce
a fluid-like substance, which allows bacteria to grow and infect the middle ear
space. A virus infection precedes up to 90% of cases of acute otitis media.

Respiratory virus infections also trigger ear infections by upsetting the body's
normal defenses in the nose and the eustachian tube, and allowing certain normal
bacteria that reside in the nose to "stick" better to the lining of the nose and
the eustachian tube. Certain viruses, such as the flu (influenza) and RSV (a respiratory
syncytial virus, or the "bronchiolitis bug"), are more frequently associated with
ear infections. Occasionally, the child's nose becomes colonized by a new aggressive
strain of bacteria, which rapidly invades the middle ear. Unfortunately, more exposures
(e.g., via daycare attendance) to viruses and new strains of bacteria increase the
likelihood of ear infections.

How common is acute otitis media?

Acute otitis media is predominantly an infection of young children, primarily occurring
in the first three years of life. Children in the 1990s experience 30% more episodes
of acute otitis media as compared with children in the 1970s, probably as a consequence
of high rates of day care. Currently, acute otitis media accounts for one-fourth
of all pediatric office visits in the first three years.

Nearly 94% of children will experience at least one ear infection in the first three
years of life, with an average of about three episodes in the first and second years,
and one and one-half episodes in the third year. As many as 5% to 8% of children
will undergo the placement of ventilating tubes in their first 24 months of life.
Much of this is related to the high rate of daycare attendance in the United States,
with increased exposure to infectious agents.

Children with a cleft palate or HIV have particularly severe problems with recurrent
ear infections.

Age affects the rate of acute otitis media, with a dramatic decline in frequency
in children older than three years. However, some children with a history of ventilating
tubes or frequent recurrent otitis media, severe allergies, or large adenoids may
still be plagued with ear problems.

Is an ear infection contagious?

To some degree, the bacteria that cause ear infections are contagious because they
may colonize, or set up residence, in the nose of children or close contacts. However,
only a small proportion of children colonized with a new strain of bacteria will
develop an ear infection. For example, in the case of pneumococcus, only about 15%
of children colonized in the nose with a new strain of it will develop an ear infection,
and usually only within the first month. Also, some bacterial strains appear more
aggressive than others and will directly invade the middle ear.

What may be even more important than new bacterial colonization is the spread of
respiratory viruses, particularly among children in daycare and pre-schools. Respiratory
viruses are very contagious in close quarters. They frequently make a child more
susceptible to an ear infection by upsetting the normal balance between the child's
local nose immunity and the co-inhabitant bacteria. When the child's defenses are
down, or the eustachian tube becomes clogged, the bacteria tend to infect the middle
ear.

How do you know if your child has an ear infection?

Children with an ear infection display a wide range of symptoms, from none at all,
to a high fever, to a screaming earache. Many infants and toddlers with an ear infection
show less obvious symptoms, such as sleeplessness, irritability, decreased feeding,
or a fever. Ear pain and ear tugging are helpful clues, but are fairly unreliable.
Even in older children with a respiratory illness, mild to moderate ear complaints
and earaches frequently occur in children with normal ears. In these children, a
sore throat often causes the ear complaints. Fever occurs in only one-fourth of
ear infections, and it does not signify an ear infection.

One of the more reliable indicators of an ear infection in younger children is when
a child, who has had a cold and a runny nose for three to seven days, suddenly develops
sleeplessness and inconsolability during the night, along with increasing fussiness
throughout the day. Children with a persistent ear infection who have recently received
antibiotics often show few symptoms.

Antibiotics should not be prescribed over the phone for a presumed ear infection,
without an examination by a physician. Only a careful examination of the eardrum
by a doctor can determine whether the ear is truly infected. Often, when the child
is brought into the office in the early phase of a cold or a mild respiratory infection,
the eardrum will be normal, only to become infected several days after the office
visit. If the child has only a mild cough and a runny nose, it is best to wait at
least five to seven days into the illness before making an office visit.

The new EarCheckTM (acoustic reflectometry instrument) may help parents to determine
whether a young child is getting an ear infection. If a previously healthy child,
who now has an illness, develops an abnormal reading on the instrument, parents
can assume a 70% chance of fluid behind the eardrum. It will not distinguish between
infected or uninfected fluid. More importantly, if the readings are normal and the
child's symptoms are mild, parents can assume that it is very unlikely that the
child has an ear infection, and an office visit may be avoided.

What does the eardrum look like when it is infected?

When a doctor examines the eardrum through the otoscope instrument, the eardrum
normally appears as a thin gray, translucent membrane (like wax paper). When infected,
it will look opacified (cloudy), very reddened, and yellowish. Sometimes, it shows
a small layer of pus-like material. During an infection, the eardrum usually becomes
rigid because of the accumulation of fluid, and it will not wiggle when the doctor
puffs a small amount of air against the eardrum with an otoscope. Use of tympanometry
or acoustic reflectometry (i.e., the EarCheck instrument) may help to determine
if there is fluid behind the eardrum. Neither instrument distinguishes between infected
or uninfected fluid.

From the appearance of the eardrum, the doctor cannot determine the type of bacteria,
or whether bacteria or viruses are causing the infection. The eardrum in children
with otitis media with effusion appears as an orangish or dull, straw-colored fluid,
and it also does not move when air is applied to it.

How is an ear infection treated?

The intense ear pain of acute otitis media can be partially relieved by adequate
doses of ibuprofen or acetaminophen. For more severe earaches, some doctors may
prescribe codeine. Numbing eardrops provide minimal relief, and only for a short
time. A warm washcloth or sweet oil (olive oil) directly instilled in the ear canal
may temporarily distract from the child's ear pain.

Nearly all doctors in the United States believe that acute otitis media should be
treated with antibiotics by mouth, particularly if the child has symptoms. Antibiotics
generally provide prompt and dramatic relief of the ear pain. Oral antibiotics for
acute otitis media are safe and effective, with exceedingly rare serious side effects.

In a few European countries, ear infections are not treated in children older than
two years, unless symptoms persist for more than 48 hours. A few U.S. physicians
recommend this same tactic.

Most experts in the United States are concerned about the tendency for pneumococcus
in an ear infection to cause more serious infections. When pneumococcus causes an
ear infection, if left untreated, it will persist in the ear of 80% of children
for up to a week. However, most episodes of acute otitis media will resolve on their
own from 3 to 10 days. Yet, non-treatment may be dangerous, not only because of
the risk of serious pneumococcus infections, but also because of the possibility
of other serious complications. Furthermore, few parents are willing to watch a
child suffer with an earache, a fever, and crying for several days.

Amoxicillin (the "pink ink") is the drug of choice for initial ear infections, except
in the penicillin allergic child. In an attempt to enhance the effectiveness of
this inexpensive and safe antibiotic, many doctors are now prescribing amoxicillin
twice a day and in double the daily standard dose. Effectiveness for initial therapy
with most antibiotics approaches 70% to 80%. There are other antibiotics to treat
children who do not respond to amoxicillin or who never seem to respond to initial
amoxicillin therapy.

Children who do not respond after two or more standard courses of antibiotics can
be expected to respond to another antibiotic only about 50% to 60% of the time.
Most children who fail antibiotic therapy are younger than 24 months, have poor
eustachian tube function, and tend to be infected with more resistant bacteria.
At this point, the easy-to-treat bacteria usually have been eliminated. The persistent
bacteria are the most resistant strains of the three most common ear bacteria. The
emergence of more resistant strains is outpacing the development of new effective
drugs. A child's doctor should be relied upon to select the most effective second-line
antibiotic choices.

The new "one-shot" (ceftriaxone) for acute otitis media also is effective for simple
cases of acute otitis media. However, "the shot" should only be used in select children,
such as those with vomiting and diarrhea, very cantankerous toddlers, or children
with an associated moderately serious illness. Three daily doses of ceftriaxone
also may be very effective in children who have failed three to four consecutive
courses of antibiotics, and are destined for tube placement.

The Centers for Disease Control (CDC) has convincingly pointed out that antibiotic
overuse is one of the major culprits for the increasing antibiotic resistance problem.
Parents should not insist on an antibiotic prescription for fevers, minor colds,
and respiratory illnesses.

Physicians almost never know which bacteria they are treating. Thus, the CDC and
other otitis experts advocate the use of tympanocentesis (lancing the ear or ear
tap) for children who have failed antibiotic therapy.

Tympanocentesis:

Relieves instantly the pain of the child with a crying earache;

Enables the physician to culture the bacteria and to select the best antibiotic for the infection; and

Allows the ear infection (like an abscess) to drain, which may improve the healing process.

The procedure can be performed nearly pain free. Only physicians who have been trained
in the procedure perform it.

No medication is currently available to treat viruses that precipitate ear infections,
either before or during the illness. An exception is the flu virus. Anti-flu medications
and the flu vaccine could help prevent some wintertime ear infections, but only
for the small number of children with ear infections related to the flu.

What are the complications?

The most serious complications secondary to ear infections are mastoiditis (infection
of the skull bone behind the ear) and meningitis (infection of the lining of the
brain). Both are extremely rare.

Chronic draining ears and chronic perforations (holes in the eardrum) are uncommon,
but occur more frequently as a result of resistant pneumococcus. However, these
complications are commonly seen in developing countries where antibiotics are not
readily available. Permanent hearing loss from very severe recurrent infections
is a major concern, but is still rarely observed with effective antibiotic therapy.
Children with an ear infection (even ones that rupture and drain) suffer only some
temporary, low grade hearing loss. As the fluid resolves, which may take months,
the hearing returns to baseline levels.

Your child's doctor may work with an ear-nose-and-throat doctor to help treat the
more severely afflicted child, or one who has suspected chronic hearing loss. Children
with chronic fluid persisting for more than four months, or with more than five
or six ear infections in a year, may require the insertion of "tubes." This is most
important during the first two years of life when hearing is critical for speech
and language development. Chronic ear infections may aggravate learning and later
school problems, but cause and effect on this issue remains speculative.

Severe complications from ear infections nearly have been eliminated, and there
is an array of antibiotics to treat them; however, the rate of highly resistant
bacteria infecting children has increased. Physicians cannot continue to wastefully
prescribe antibiotics, and parents should not demand them to treat everyday colds
and viral infections. Although the new Prevnar vaccine may prevent many strains
of highly resistant pneumococcus, with continual antibiotic misuse, microbiologic
history will repeat itself in other pneumococcal strains or in other bacteria.

What research is being done?

The most important recent development to potentially reduce the frequency of ear
infections is a new pneumococcal conjugate vaccine. A study from Northern California
suggests that this vaccine could prevent about 7% of overall episodes of ear infections,
and up to 23% of recurrent ear infections.

The new pneumococcal vaccine contains 7 of 90 types of pneumococcus, which are the
most common and the most resistant bacteria. Elimination of these resistant types
could have an impact on the number of antibiotic failures in children. This also
could mean a reduction in the placement of tubes, possibly by one-fourth, as observed
in the California study.

This vaccine is administered to infants at 2, 4, 6, and 12 months of age. Side effects
have been minimal, and it has been a very safe vaccine. It uses the same technology
as the universally administered HIB vaccine.

Some new antibiotics are about to undergo testing in children with acute otitis
media. In preliminary testing, these drugs appear to work against the resistant
pneumococcus.

In the future, there may be alternate ways of treating or preventing ear infections.
A new antibiotic may be able to penetrate the eardrum directly by instilling eardrops.
A nasal spray squirted in the nose of infants a few times a day may prevent the
common bacteria of acute otitis media from gaining access to the nose. Some Scandinavian
investigators have shown slight reduction in the number of ear infections in children
who regularly used an experimental sugar called xylitol.

Dr. Block is a full-time practicing pediatrician in rural Bardstown, Kentucky who
serves on the clinical faculties at both the University of Kentucky and the University
of Louisville as an Associate Clinical Professor of Pediatrics.

His pediatric practice is one of the leading pediatric research groups in the United
States and, in fact, Dr. Block was awarded the American Academy of Pediatrics 1998
Practitioner Research Award.

He has authored and published over 20 articles and 40 abstracts on pediatric infectious
diseases. He has also lectured on Otitis Media extensively to pediatricians and
other physicians throughout the U.S. and Canada.

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